Behavioral Health Workforce Pipeline Mapping Project

Nevada Department of Health and Human Services

Division of Public and Behavioral Health

May 2014

Nevada Licensed Behavioral Health Professional Education and Training Facilities

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UNSOM- Offers 3-year Psychiatry Residency Program in Las Vegas and Reno http://medicine.nevada.edu/reno/psychiatry/education/residency/curriculum and http://medicine.nevada.edu/las-vegas/psychiatry

UNLV and UNR average 5-6 year PhD programs. Service contracts help support UNR students; UNLV fully supports with GA slots http://www.unr.edu/PSYCH/clinical/index.html and http://psychology.unlv.edu/clinical.htm

UNLV and UNR offer 46 credit, and 52-54 credit Family Nurse Practitioner programs: estimated cost $25,000 http://www.unlv.edu/degree/post-ms-family-nurse-practitioner and http://www.unr.edu/degrees/nursing/fnpagc

Carrington College, CSN, GBC, Kaplan College, NSC, Roseman U., Touro U., TMCC, UNLV, UNR, and WNC http://nevadanursingboard.org/wp-content/uploads/2013/04/nursingprograms.pdf

UNLV and UNR offer BSW (120-124 credits- estimated $25,000) and MSW (62-63 credits- estimated $22,000) programs http://www.unlv.edu/socialwork and http://www.unr.edu/degrees/social-work/msw

UNR offers a 64-credit MA degree to be completed in 6 years. UNLV offers a 60-credit MS degree. http://mft.unlv.edu/grad.html and http://www.unr.edu/degrees/counseling-and-educational-psychology/ma

UNLV and UNR offer undergraduate minor (18-21 credits – estimated $3830) in addictions and masters in counseling (estimated $3168) http://casat.unr.edu/academics.html and http://education.unlv.edu/ecs/undergraduate/minor_treatment.html

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Recommendations for Education and Training Expand Training Programs

• Develop full Psychiatric Nurse Practitioner programs

• Develop certification program in integrated behavioral health, including substance use disorders

• Create new psychiatric resident paths for child/adolescent, forensics, geriatric, neurology, family medicine and triple board programs

Leverage clinical settings

• Cross-train Family Nurse Practitioners into psychiatry programs through clinical services programs

• Develop residency programs for Psychologists and Psychiatric Nurse Practitioners

• Increase accredited internship sites and paid internships across all behavioral health professions

• Develop incentives for licensed professionals who are willing to supervise interns

• Develop blended clinical supervision roles to share responsibilities between employers and educational institutions

Leverage public and private insurance

• Include training for billing Medicare, Medicaid and private insurance in health professional curriculum

• Develop reimbursement model to support faculty with clinical revenue

Seek additional financial support

• Create more graduate medical education slots for psychiatry students

• Create more graduate assistant slots for 1st and 2nd year doctoral psychology students

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Nevada Licensed Behavioral Health Professions with Licensing Boards and Requirements

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Board of Medical Examiners http://www.medboard.nv.gov/ or Board of

Osteopathic Medicine http://license.k3systems.com/LicensingPublic/app?page=main&service=page

Board of Psychological Examiners http://psyexam.nv.gov/

Board of Nursing http://nevadanursingboard.org/

Board of Nursing http://nevadanursingboard.org/

Board of Examiners for Social Workers http://socwork.nv.gov/

Board of Examiners for Marriage and Family Therapists and Clinical Professional Counselors http://marriage.nv.gov/

Board of Examiners for Alcohol, Drug and Gambling Counselors http://alcohol.nv.gov/

BME:USMLE exam and completion of post-graduate training BOM: National and state exams and completion of post-graduate training

EPPP (national) and state licensure exam. 1,750 hours for pre-doctoral internship plus 1,750 hours for post-doctoral residency.

Require national cert/ exam as of June 2014. Endorsement from other jurisdiction is relatively easy; temp license = 6 months; Renewal = 45 CEs every 2 years

National Council Licensure Examination qualifies for ALL states. Apply for NV endorsement. Renew every 2 years.

Exam through Association of Social Workers Board w/NV endorsement based on substantially equivalent standards. 3000 hours supervised post-graduate work.

Licensed MFT interns are eligible to take National Marital and Family Therapy Exam following one full year as licensed MFT intern. Licensed CPC-Interns are eligible to sit for the National NCMHCE exam after passing the Academic Review and before expiration Internship

CADC: Bachelor’s degree w/4000 hours LADC: Master’s degree w/4000 hours LCADC: Master’s degree w/4000 hours including mental health treatment. 2500 hours waived if minor in addictions. 2 years of recovery/ abstinence if addicted

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Recommendations for Licensing Boards

Strengthen Process

• Establish online FAQs on all licensure websites and provide outreach to training programs to educate students about requirements and process

• Develop transparent process for employers to collaborate on validation of core competencies and clinical expertise, and documentation thereof, to provide support for out-of-state applicants

• Expand scope of tele-health for both practice and supervision

Support Workforce Development

• Collect minimum data set across all professions; consider cross-board collaborative to support online data collection

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Scope of Practice P

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http://www.abpn.com/downloads/core_comp_outlines/2011_core_P_MREE.pdf

http://www.abpp.org/i4a/pages/index.cfm?pageid=3846

http://nevadanursingboard.org/practice-and-discipline/scope-of-practice-determination/scope-of-practice/

http://leg.state.nv.us/NAC/NAC-641B.html#NAC641BSec200

http://leg.state.nv.us/NAC/NAC-641A.html

http://leg.state.nv.us/NAC/NAC-641C.html

1. Mental and neurological exam; 2. DSM diagnosis, case formulation, evaluation plan, and treatment plan. 3. Assess for potential harm 4. Therapy and intervention 5. Determine if disease 6. Integrated therapy 7. Prescribe psychotropic medications 8. Evaluate for advanced therapies

Provide all types of psychotherapy services, with demonstrated training or experience. Psycho-educational, neuropsychological, and psychological assessments can be performed. In limited circumstances (e,g, competency evaluations) special certification is required in addition to licensure.

Dependent on coursework and documented competence. Educated in role (NP, CNS, or NM) and a population (women’s health, family health and caring for the patient across the life span, mental health, adult health, gerontology, pediatrics, and/or neonatal.

Prefer national certification as a psychiatric RN. RN Includes observation, care and counsel of the ill, injured or infirm, maintenance of health or prevention of illness of others, supervision and teaching of personnel, administration of medications and treatments, as prescribed.

Psychotherapeutic methods and techniques, such as the use of individual, couples, family and group therapy, to: understand unconscious processes and intrapersonal, interpersonal and psychosocial dynamics; and diagnose and treat mental, emotional and behavioral disorders, conditions and addictions.

Diagnosis and treatment of mental and emotional disorders-cognitive affective or behavioral-within relationship context. Provide psychotherapy, counseling, evaluation, assessment, consultation, treatment planning, supervision, research and prevention. Serves person, couple, family or other group.

Assess and counsel a person with a substance abuse disorder (SUD); families may be seen in the context of the identified patient’s SUD. LCADC can assess and counsel a person with a co-occurring mental health and SUD problem, but can’t see someone with mental health issue, only.

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Recommendations for Scope of Practice

• Conduct system-wide survey on supervision practices, including frequency, content, training in EBP, adherence to supervisory EBP, and level of training a supervisor has had to qualify for supervisory status

• Clarify ability of psychologists to provide consultation to primary care providers and/or consumers regarding psychotropic medications

• Clarify scope for APRN, FNP or Adult NPs practicing in psychiatric setting without formal education. Recommend successful completion of the ANCC Psychiatric Mental Health Nurse Certification www.nursecredentialing.org/psychiatricmentalhealthnursing

• Include Code of Ethics in NRS Chapter 641B for Social Workers

• Require completion of the minor in addictions for AOD Counselors, before an intern can practice

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Nevada Licensed Behavioral Health Professions

Medicaid and Medicare Reimbursement See http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Mental_Health_Services_ICN903195.pdf and

http://www.integration.samhsa.gov/financing/Nevada_Billing_and_Financial_Worksheet.pdf

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Qualified for Medicaid and Medicare Reimbursement

Licensed Clinical Psychologist qualifies for Medicaid and Medicare reimbursement

Qualified for Medicaid; reimbursed for Medicare Part B at 85% of physician rate

Limited scope billing for Medicaid; Ineligible for Medicare billing

Qualified for Medicaid and Medicare Part B. Interns qualify for Medicaid; not telemedicine

Qualified for Medicaid as Provider Type 14, including interns through Board approved site. Not qualified for Medicare.

CADC, LADC and LCADC can bill Medicaid as Provider code 17, if they are under a SAPTA-funded agency. Not qualified for Medicare.

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Recommendations for Medicaid Rate Increases

• Increase facility fees; consider cost-based reimbursement similar to FQHCs and RHCs (see Medicare demonstration); incremental implementation

• Increase reimbursement rate for psychologists based on extended scope of practice

• Increase reimbursement rate for APRN based on expanded scope of practice

Expand Coverage

• Extend reimbursement to Psychiatric Nurses within scope of practice

• Upgrade LCADC to Qualified Mental Health Practitioner status for Medicaid reimbursement

• Expand reimbursement to interns and support staff for all behavioral health professions

• Expand reimbursement for tele-health, including urban areas and supervision

• Consider no-show rates for medically challenging patients

Improve Outreach

• Provide updated panel listings on a regular basis

• Streamline approval process for pre-authorization for psychological testing

• Keep NSHE and Licensing Boards informed about changes to Medicaid that impact the preparation of health professionals.

Support Resident training

• Consider sponsorship of Graduate Medical Education slots

• Change clinical supervision language to exclude use of interns as clinical supervisors; must be licensed with at least 2 years of clinical experience

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Recommendations for Medicare

• Streamline process for SSI/SSDI eligibility

• Expand authorization for completing disability assessment

• Consider centralized contracting process with standard rates

• Expand reimbursement to all behavioral health providers

• Expand reimbursement for case management and rehabilitative services

• Increase reimbursement for Nurse Practitioners/Certified Nurse Specialists to level of Primary Care Providers

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Nevada Licensed Behavioral Health Professions State Personnel Classifications

http://hr.nv.gov/Resources/ClassSpecs/10/10_0a-Psychiatric/ P

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Unclassified ($155,621 - $176,902). Certification by the American Board of Psychiatry and Neurology within 5 years of employment. English language proficiency. Facility license supports practice in MH center of DPBH under direct supervision of psychiatrist with unrestricted license.

Psychological Assistant (Grade 41): Doctoral degree and board approval. Psychologist (Grade 44): Doctoral degree and license. Psychologist II (Grade 45) Salary range from $59,195 to $107,114.

Licensure by NSBME or NSBOM or certification from NSBN (Grade 43) Salary range from $64,707 to $97,593

Licensed RN + 1 yr professional experience, or 1 yr as RN 1 in state service with psychiatric or DD patients, or equivalent combination. LPNs may also practice as Psych Nurse. (Grade 37-43) Salary range from $49,694 to $97,593.

Provide case management and intervention for individuals and families. Know laws governing abuse and neglect, and effect of Substance Abuse. CSW I (Gr35): Masters degree + approved internship; CSW II (Gr37): above + licensure; CSW III (Gr39): above + management. Salary range $45,460-$81,139

Licensed MFT and CPC qualify for: MH Counselors, Developmental Specialist, Psychological Developmental Counselors, and Psychiatric Caseworkers. (Grade 35-43) Salary range $45,560 - $97,593.

There is no state classification for Alcohol and Drug Counselors. State program administers sub-grants to community providers for all these services.

2/11/2015 Nevada Division of Public and Behavioral Health 11

Recommendations for State Personnel Increase Salaries

• Increase salaries for psychiatrists, psychologists and nurses

• Revise class specification for Clinical Social Workers based on licensure requirement: upgrade CSW 1 from 35 to 37; CSW II from 37 to 39; CSW III from 39 to 41. Add CSW IV (43) and CSW V (45) to mirror track for MH Counselor series.

Supplemental Support

• Consider covering travel, relocation, CME and licensure costs

• Consider shift differential for inpatient, after hours, or emergency call

• Consider incentive pay for dual certification

• Develop promotional steps and annual COLA

• Develop incentives for licensed professionals willing to provide supervision for interns.

• Reinstate 5% pay for bilingual staff and for hard to fill locations, e.g. critical shortage areas

• Improve process to request accelerated pay for a new hire

Develop Career Pathways

• Promote general career path, and develop state-career path for under/graduate social work students, and include specialties, such as child therapy and rural social work

• Create state positions for clinical internship to include job duties specific to supervising interns

Develop Marketing Campaign

• Address stigma with PSAs from American Psychiatric Association;

• Ask Governor et al to do welcome at annual NPA meeting in Las Vegas and talk about steps to improve BH system in Nevada;

• Do mini-internships for Legislators and others to spend a day with BH professionals

Expand Outreach

• Add cultural competence to the Knowledge, Skills and Abilities section of the class series for all social service providers.

• Expand definition of Cultural Competence: The delivery of services responsive to the cultural context of racial and ethnic minority groups, as well as differently abled or oriented groups, including but not limited to their languages, histories, traditions, beliefs and values.

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Nevada Licensed Behavioral Health Professions Loan Repayment and Scholarship

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1. National Health Service Corps (NHSC) Scholarship provides stipend, tuition and related costs up to 4 years in exchange for service at NHSC site. 2. Nurse Corps Scholarship provides stipend, tuition and related costs for up to 4 years in exchange for service at critical shortage facility. 3. NHSC Student-2-Service provides up to $120,000 loan repayment in exchange for 3 year full-time service commitment or 6-year half-time commitment. 4. WICHE Health Care Access Program Scholarship provides up to $16,667 annually for 2-4 years for service to underserved populations in Nevada. 5. NHSC Loan Repayment provides up to $50,000 for 2-year service obligation plus up to $20,000 for years 3-4, and $10,000 for years 5+ in NHSC site. 6. Nursing Corps Loan Repayment provides funding based on financial need and facility where you work for 2-year minimum at a critical shortage facility. 7. WICHE Health Care Access Program for Loan Repayment provides up to $14,400 for 1 year full-time service to underserved populations in Nevada. 8. State Loan Repayment program provides up to $60,000 for 2-year service obligation; opportunity for $20,000 for every additional year at NHSC site.

Must be US citizen or national; nursing corps includes lawful permanent residents. NHSC sites must provide services regardless of ability to pay.

Psychiatrists are eligible for programs 1,3, 5, 7 and 8.

Psychologists are eligible for programs 5, 7 and 8.

APRNs are eligible for programs 1, 2, 4, 5, 6, 7 and 8.

Psychiatric nurses are eligible for programs 2, 4, 5, 6, 7 and 8.

LCSWs are eligible for programs 5, 7 and 8.

MFTs and CPCs are eligible for programs 5, 7 and 8

There are no known loan repayment programs at UNR or UNLV for LADCs.

Links: 1. http://nhsc.hrsa.gov/scholarships/index.html 2. http://www.hrsa.gov/loanscholarships/scholarships/Nursing/ 3. http://www.nhsc.hrsa.gov/loanrepayment/studentstoserviceprogram/ 4. http://www.wiche.edu/nv 5. http://www.nhsc.hrsa.gov/loanrepayment/index.html 6. http://www.hrsa.gov/loanscholarships/repayment/nursing/ 7. http://www.wiche.edu/nv 8. kclark@medicine.Nevada.edu 2/11/2015 Nevada Division of Public and Behavioral Health 13

Recommendations for Loan Repayment and Scholarship Programs

• Need state resources to promote programs and provide matching funds

• Work with NSHE to promote scholarship and loan repayment programs and provide contacts

• Establish loan repayment and scholarship programs for AOD Counselors

• Create a link on DHHS website with contacts to assist applicants

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